Medical
Endovascular
Surgical Simulation: The CathLabVR System
The virtual-reality CathLabVR System fills roughly the same space as real cath lab equipment and includes:
- Two monitors, one for displaying fluoroscopic views, Virtual Assistant functions, navigation control, and simulated patient information; the other for displaying physio, cine, and still images, controls for the C-arm — as well as total procedure running time, fluoroscopy and cine radiation time, and contrast instilled
- A manifold for contrast instillation, balloons, balloon stents, guidewire, and catheter
- A foot pedal used to capture cines and control fluoroscopy; a joystick to maneuver the simulated C-arm; and a keyboard and mouse to make onscreen selections
Multiple endovascular simulation modules cover a variety of situations and procedures:
- Coronary and peripheral vascular interventions
- Cardiac pacing
- Cardiac valve replacements
- Carotid interventions
Realistic in Every Detail
The SmartCapture tool recognition enhances realism by automatically recognizing and responding to instrument insertion and removal. The simulator uses four carriages enabling the insertion and rotation of up to four instruments simultaneously. In addition, the CathLab VR simulator’s physics-based haptic engine provides realistic changes in simulated physiology.
Read more about CathLabVR System
Integrated Haptics
Patented force feedback technology integrated with visual and audio responses mimics the look and feel of an actual surgery. Users actually feel the forces encountered when navigating interventional catheters, wires, balloons, and stents within the virtual patient’s anatomy. This helps to promote training in proper tool selection and tool-handling techniques within the virtual anatomy.
Multiple Simulated Cases
The module includes training on placing balloons and stents in stable and unstable patients. The simulation provides an ideal environment for surgeons to practice and perfect minimally invasive endovascular skills in an objective, repeatable, non-threatening training environment.
The simulator also allows team training for the physician and allied health personnel who will work together in the procedure.
Computer-generated Simulations
The CathLabVR System uses computer-generated models that closely reproduce the anatomical variations and physiology of a wide range of patients. A real-time display of fluoroscopic and cine images provides realistic rendering with emulation of digital zoom allowing evaluation of case-specific pathology and subsequent interventions. The simulation provides an ideal environment for surgeons to practice and perfect minimally invasive endovascular skills in an objective, repeatable, non-threatening training environment.
Realistic Changes in Simulated Physiology
The comprehensive physics-based surgical simulator reacts appropriately to the manipulation and deployment of actual diagnostic and therapeutic devices, providing practice in accessing and navigating through diverse anatomy. The appropriately responsive physiology is reflected in changes in vital signs, hemodynamic wave tracings, and patient responses, which enhance the decision-making process. Depending on the underlying anatomy, these decisions will impact the time to successfully complete the case, as well as in determining whether not the problem lesions are effectively resolved.
A variety of cases with increasing difficulty call for the management of complications, allowing users to assess and perfect their skills. Measurable outcomes and metrics allow for objective assessment of users.
Due to the different anatomical variations of the virtual patients, users may need to select a different guide catheter, guidewire, and/or lead to improve the success of navigating to the desired location. For successful completion of the case, trainees need to test leads prior to and after fixation to confirm optimization of sensing and stimulation thresholds, and to withdraw all delivery instruments and devices without damaging any of the surrounding tissues.
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Percutaneous Coronary Interventions and Advanced Coronary Interventions
The Percutaneous Coronary Intervention (PCI) surgical simulation modules (PCI and Advanced PCI) each provide 10 progressively difficult cases that include patient history and pre-procedure steps that have been completed to prepare the virtual patient.
For complete, effective surgical training, the modules include:
- High-fidelity surgical devices, tools, displays
- Training for endovascular complications
- Objective, automated training evaluation
High-fidelity Surgical Devices, Tools, Displays
Integrating realistic tactile feedback, the user will actually feel the forces encountered when navigating and deploying interventional wires, balloons, and stents through the virtual anatomy.
Various types of virtual instruments, such as Amplatz, Judkins, or hockey-stick catheters are available for navigating through torturous anatomy, including anterior take offs, shepard’s hook, and saphenous vein grafts.
The surgical simulator’s virtual reality fluoroscopic display can be rotated and magnified, and cine video loops and still images can be recorded as they are in a real catheterization lab. Real-time ECG, blood pressure, heart rate, and arterial pressure wave sensing are indicated to monitor the virtual patient’s status throughout the case.
Training for Endovascular Complications
The CathLabVR Surgical Simulator supports training in proper tool selection and in tool-handling within the virtual anatomy. Improper technique or tool selection can cause complications. To complete a simulated case, complications must be recognized and treated.
Objective, Automated Training Evaluation
Criteria tracked during the case includes:
- Total fluoroscopy time
- Amount of contrast used
- Final placement
- Whether complications were elicited and addressed appropriately
- Percentage of the lesion opening compared to pre-procedure percentage
- If the entire lesion length was covered by the stent
Anatomy and complications specific to each module
Percutaneous Coronary Interventions Module
The PCI module’s simulated surgeries include:
- Various aortic arch sizes such as dilated aortas
- Different coronary artery structure
- Different types of arterial lesions, both calcified and non-calcified
- Complications: dampening at the ostia, dissections, perforations, stent embolization
Advanced Percutaneous Coronary Interventions Module
The Advanced Coronary Interventions module’s simulated surgeries include more complicated presentations, such as:
- Additional ostia to cannulate for saphenous vein grafts
- Calcified and non-calcified lesions distributed throughout the anatomies
- Chronic total occlusions and dislodged thrombus that require an intervention plan
- Complications: dampening at the ostia of the coronary artery, dissections, perforations, stent embolization, thrombus dislodgement, spasm, bradycardia
The module also includes:
- An extensive library of complications
- A wide variety of adjunct therapies: adenosine and nitro-glycerin; defibrillation and temporary pacing leads
All selections are tracked and displayed in the evaluation metrics, including decisions such as under- or over-dosing of medications.
Cardiac Rhythm Disease Management
The Cardiac Rhythm Disease Management (CRDM) modules for the CathLabVR System include simulations for bradycardia and heart failure. They allow the user to practice selective placement and fixation of cardiac pacing leads within a virtual 3D model of a beating heart using:
- Real-time fluoroscopic images
- Unique pacing tools
- Virtual-reality heart monitoring
Real-time Fluoroscopic Images
The surgical simulator’s fluoroscopic image may be rotated or magnified, and clinicians can record cine video loops or still images as in a real catheterization lab. An image of the virtual patient’s heart chambers and venous anatomy serves as a virtual aide to assist with identifying significant anatomy to help with the navigation of the pacing leads and other devices.
Unique Pacing Tools
The CathLabVR surgical simulator allows unique pacing tools, such as deflectable and steerable catheters, which are especially helpful for cases with torturous anatomy or hard-to-get-to locations. Users can shape or customize guidewires and stylets to help navigate the pacing lead. Both pre-shaped passive-fixation and active-fixation leads, as well as over-the-wire and stylet-driven leads are available for cardiac rhythm cases
Virtual-reality Heart Monitoring
The virtual patient’s heart is electrophysiologically appropriate. Pacing from the various locations produces responsive changes in the ECG signal. Real-time surface ECG leads may be evaluated. Pacing from certain anatomical locations can stimulate the phrenic nerve, causing diaphragmatic stimulation. Movement of the heart and the diaphragm can be observed on the real-time virtual reality fluoroscopy display.
The CRDM modules also allow users to evaluate the electrical performance of the pacing lead once it has been placed; and to test stimulation and sensing thresholds, and the effect of 10-volt pacing.
Objective, Automated Training Evaluation
Criteria tracked during the cases includes:
- Total fluoroscopy time
- Contrast used
- Complications encountered and treated
- Final placement
- Electrical characteristics of the final lead position
- Whether fixation of the lead was successfully accomplished
- Whether diaphragmatic stimulation was present
Anatomy and complications specific to each module.
CRDM Bradycardia Module
The CRDM Bradycardia module allows the user to practice using fixed-shape or deflectable/steerable catheters to navigate active or passive fixation leads to either an atrial or ventricular location, or for cannulation of a coronary sinus for a left ventricular epicardial placement. The simulated cases include various heart chamber sizes with:
- Dilated ventricles
- Coronary sinus locations
- Tight or truncated atrial appendages
CRDM Heart Failure Module
The CRDM Heart Failure module provides practice using fixed-shape or deflectable/steerable catheters to cannulate the ostium of the coronary sinus. The cases include:
- Various heart chamber sizes and coronary sinus locations
- Dilated chambers
- Large, distorted, or tortuous coronary sinus anatomy
Once the sinus is engaged, the user may:
- Place a special venogram balloon-catheter within the virtual patient’s coronary sinus
- Inject contrast to record a cine video loop or still image
- Examine the course of the coronary sinus and its tributaries
- Select appropriate stylet-driven or over-the-wire pacing leads
- Remove the delivery catheter and guidewire or stylet without dislodging the pacing lead
Transcatheter Aortic Valve Repair
The CathLabVR endovascular simulator’s Transcatheter Aortic Valve Repair module provides practice in both femoral (retrograde) and trans-apical delivery of the aortic valve repair system including:
- Navigating a variety of catheters and guidewires through the cardiac and aortic anatomy
- Performing balloon aortic valvuloplasty
- Using fluoroscopy, cineangiography, and contrast injection to visualize the aortic valve annulus
- Delivering the transcatheter aortic valve
Computer-generated, real-time fluoroscopic images of the virtual reality patient permit users to visualize the selected interventional catheterization instruments. A range of cases expose the user to patients of varying ages and degrees of stenoses, calcification, and regurgitation. Each case includes a patient history and pre- and post-procedure treatment steps. It also allows clinicians to:
- Evaluate nonworking valves
- Evaluate learning progress and competency
Read more about Transcatheter Aortic Valve Repair
Evaluate Nonworking Valves
The aortic valve module allows the user to evaluate anatomy through cine and still fluoroscopic images from different angles. Using cines and stills, users can perform quantitative angiography to determine the size of the balloon or stent needed to repair the native or prosthetic aortic valve.
Injecting contrast from a position in the aortic bulb allows the physician to evaluate:
- The degree of stenosis/regurgitation
- The presence of peri-valvular leakage after placement of the stent/valve
- Blood flow into the coronary arteries during the case
Evaluate Learning Progress and Competency
The user and system administrators can evaluate performance on:
- Total fluoroscopy time Amount of contrast used
- Complications encountered Peri-valvular leakage
- Coronary obstruction Mitral impairment Stent embolization
Basic and Advanced Carotids Module
At least half a million strokes are diagnosed each year. Catheter-based endovascular procedures like carotid angioplasty and stenting can be the best approach for some patients. Yet these procedures require intensive training and several procedures to perfect. Immersion TouchSense® haptic-enabled simulation gives clinicians the ability to learn and maintain these skills without the use of animals or human cadavers and without the cost or risk of training during an actual procedure.
The CathLabVR Surgical Simulation System's Carotid module provides realistic interactions, a superior learning environment and training on key tools, by including the following:
- Physics-based interactions.
- Physiologic monitoring and responses.
- Neurological status updates.
- A realistic CathLab environment.
- Objective, automated metric evaluations.
- Independent training not requiring a physician mentor onsite.
- Repeatability of procedures in a low stress environment.
- Pharmacologic and non-pharmacologic adjunct therapies.
- Embolic protection devices (EPD).
- Various guidewires.
- Diagnostic and guide catheters.
- Balloons and stents.
Both modules include complications with consequences that must be recognized and treated within an appropriate timeframe. Some of the complications included are:
- Artery perforation.
- Artery dissection.
- Artery spasm.
- Thromboembolism and the dislodgement of embolic material.
Read more about this endovascular module
The new module provides multi-modal (sight, sound and touch) virtual reality lifelike training of carotid angioplasty and stenting, a non-invasive procedure performed to help prevent strokes – the third leading cause of death in the United States. Powered by Immersion’s programmable high-fidelity haptic feedback, it provides a realistic simulation of an actual procedure outside the CathLab and operating room where doctors can practice and perfect their skills of this sophisticated technique prior to performing it on a live patient.
Realistic Endovascular Interventional Simulation Training
The Carotid module helps users practice various treatment techniques for coronary artery stenosis, including the use of guidewires, catheters, balloons, stents and embolic protection devices in a realistic environment. The realism is created by including:
- Immersion’s TouchSense patented force feedback technology integrated with visual and audio responses to mimic the look and feel of an actual surgery.
- Comprehensive physics-based virtual models that closely reproduce patient anatomy.
- SmartCapture tool recognition that enhances realism by automatically recognizing and responding to instrument insertion and removal.
- The ability to insert and rotate up to four instruments simultaneously, and real-time display of fluoroscopic and cine images to provide realistic rendering.
- Patient vital signs and neurological status in real-time.
- A Virtual Attending feature provides instructional feedback to the user during the procedure.
Evaluation Report Offers User-Specific Documentation
A thorough evaluation report is automatically generated every time a user completes a case. All reports are stored in a database to provide user-specific documentation of training and competency. Items recorded include:
- Time to complete the procedure.
- Total Fluoroscopy time.
- Total volume of contrast delivered.
- Degree of stenosis prior to and post intervention.
- Occurrence and treatment of complications.
- Review of recorded still images.
Training Objectives for Proficiency
The Carotid Interventions module focuses on the navigation of various endovascular equipment used to perform angiographic studies to identify the presence of carotid artery pathology. Subsequent to the study, the user performs interventional techniques including balloon angioplasty and stenting.
In this module, you will:
- Practice cannulating the subclavian, brachiocephalic, vertebral and carotid arteries.
- Evaluate the patients’ carotid artery diseases by performing carotid angiography using contrast media.
- Become familiar with the carotid anatomy and its variations through the virtual 3-D anatomy model.
- Practice using interventional guide wires to navigate through the diverse carotid anatomy.
- Practice using a variety of balloons, stents, sheaths and catheters commonly used during percutaneous carotid interventions.
- Practice using various types of embolic protection devices.
- Understand and/or recognize complications based on vital sign changes, visual signs and auditory responses from the simulated patient.
Medtronic, Inc.
Endovascular Simulator Enhances Patient Safety and Physician Training
Challenge
- Enhance patient safety
- Provide more experience in less time
- Reduce complications
Solution – Medical Virtual Reality with Immersion’s Endovascular AccuTouch® System
- Provide scenarios that represent everyday events
- Give experience with using fluoroscopic display
- Use Immersion TouchSense technology to simulate the forces encountered during the procedures
- Allow risk-free practice in navigating various endovascular guide wires and catheters
Outcome
- Taught physicians to recognize, respond to, and avoid procedure complications
- Provided more experience with potential complications than ordinary exposure
- Focused training on recurring problem areas
- Allowed independent practice and team training
Medtronic, Inc.
Simulation Helps Cardiologists Achieve Better Performance and Faster Competency
Challenge
- Support integration of classroom training on interventional cardiology skills
- Provide opportunity for richer skills development
- Increase number of Chinese doctors who could receive training
Solution – A Richer Training Experience with Immersion’s Endovascular AccuTouch System
- Allow students to spend more time on skills training
- Expose trainees to more types of cases with increasingly difficult anatomic variations
- Simulate complications such as perforation, vessel rupture, and cardiac arrest
- Enable students to both practice basic principles and manage unexpected situations
Outcome
- Achieved better performance and less time to complete a procedure
- Required fewer procedures to reach competency
- Allowed doctors to repeat a case to learn how an alternative approach could lead to a better outcome
